Mood Disorders

Goals of Interdisciplinary Treatment Reduce, remove symptoms. Restore occupational and psychosocial functioning. Reduce likelihood of relapse. Safety is a priority. Suicide assessment 12

Family Response Affects the whole family Often has financial hardships

Priority Care Issues Safety Risk for suicide

Nursing Management: Biologic Domain Assessment Systems Review (CNS, endocrine, anemia, chronic pain, etc.) Physical exam: palpation of the neck for thyroid abnormalities Appetite and weight Sleep disturbance Decreased energy 19

Nursing Diagnosis: Biologic Domain Disturbed sleep pattern Imbalanced nutrition Fatigue Many other possible Failure to thrive Bathing/hygiene deficit Pain

Psychopharmacologic Interventions Cyclic antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine, sertraline, fluvoxamine, paroxtine, citalopram, escitalopram Monoamine Oxidase Inhibitors (MAOIs) Phenelzine (Nardil), Tranylcypromine (Parnate) Atypical antidepressants Trazodone, bupropion, nefazodone, venalfaxine and mirtazapine 13

Pharmacological Nursing Interventions Monitoring and Administration Observe taking meds (acute phase) Vital signs (observe for orthostatic hypotension), lab reports Diet restrictions as appropriate

Side Effects: SSRIs GI Distress Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Low Anticholinergic Fluoxetine (Luvox) Low sedation (All) Sexual Dysfunction (All) Orthostatic Hypotension Fluoxetine (Prozac) Fluvoxamine (Luvox)

Side Effects of TCAs: Anticholinergic and Antihistaminic Sedation and drowsiness Weight gain Hypotension Potentiation of CNS system drugs Blurred vision Dry mouth Constipation Urinary retention Sinus tachycardia Decreased memory 14

Monamine Oxidase Inhibitors Indications Depression with personality disorders, panic or social phobia Side Effects Hypertensive crisis/interaction with food Sudden, severe pounding or explosive headache Anticholinergic Elderly - sensitive to orthostatic hypotension Sexual dysfunction 16

Serotonin Syndrome More likely to be reported in patients taking two or more serotonin antagonists Usually mild, but can cause death Rapid onset (compared to NMS) Symptoms Mental status, agitation, myoclonus, hyperreflexia, fever, shivering, diaphoresis, ataxia and diarrhea Treatment Stop offending drug. Provide supportive treatment. Notify physician.

Drug-drug Interactions SSRIs inhibit 1A2 system. (Theophylline must be reduced.) Smoking induces 1A2 system; smokers may need higher dosage. Fluoxetine and paroxetine inhibit 2D6. Can increase plasma levels of TCA, so avoid giving these meds with TCA.

Amitriptyline Butriptyline Clomipramine Desipramine Dosulepin Doxepin Imipramine Iprindole Lofepramine Nortriptyline Protriptyline Trimipramine

Teaching Points If depression goes untreated or is inadequately treated, episodes become more frequent, severe and longer in duration. Importance of continuing medication

Nursing Management: Assessment Psychological Assessment scales self-report Mood and affect Thought content Suicidal behavior Cognition and memory 20

Nursing Diagnoses Psychological Domain Anxiety Decisional conflict Fatigue Grieving, dysfunctional Hopelessness Self-esteem, low Risk for suicide 22

Psychological Interventions Nurse-Patient Relationship Withdrawn patients have difficulty expressing feelings. Nurse should be warm and empathic, but not a cheerleader. Therapeutic Dialogue. 23

Psychological Interventions Cognitive therapy - psychotherapy Behavior therapy Interpersonal therapy Marital and family therapy Group therapy Patient and family education 24

Nursing Management: Assessment Social Domain Developmental history Family psychiatric history Quality of support system Role of substance abuse in relationships Work history Physical and sexual abuse 21

Social Nursing Interventions Patient and family education Medication adherence Marital and family therapy Group therapy 25

Continuum of Care Non-psychiatric setting Acute care – hospitalization Outpatient 26

Types of Bipolar Bipolar I Bipolar II Combinations of major depression and full manic episode Mixed episodes: alternating between manic and depressive episodes Bipolar II Combination of major depression and hypomania (less severe form of mania) 2

Treatment Issues Complex issues treated by an interdisciplinary team Priority issues: Safety from poor judgement and risk-taking behaviors Risk for suicide during depressive disorders Devastating to families, especially dealing with the consequences of impulsive behavior

Nursing Management: Biologic Domain Assessment Evaluation of mania symptoms Sleep may be nonexistent. Irritability and physical exhaustion Eating habits, weight loss Lab studies - thyroid Hypersexual, risky behaviors Pharmacologic (may be triggered by antidepressant), alcohol use Nursing diagnosis Disturbed sleep pattern, sleep deprivation Imbalanced nutrition, hypothermia, deficit fluid balance

Nursing Interventions: Biologic Domain Physical care Pharmacologic Acute - symptom reduction and stabilization Continuation – prevention of relapse Maintenance - sustained remission Discontinuation - very carefully, if at all Electroconvulsive therapy

Mood Stabilizers Lithium Carbonate (Eskalith) Mechanism of action: unknown Blood levels 0.5-1.2 Side effects: GI, weight gain Divalproex Sodium (Depakote) Increase inhibitory transmitter, GABA Sedation, tremor Carbamazepine 10

Mood Stabilizers Lithium Carbonate Drug profile Lithium blood levels Divalproex sodium (Depokote) (Drug Profile) Carbamazapine (Tegretol) Baseline liver function tests and complete blood count Newer anticonvulsants Lamotrigine (Lamictal) Gabapentin (Neurontin) Topiramate (Topamax)

Other Medications Used Antidepressants Used during depressed phases Can trigger manic phase Antipsychotics Psychosis Mania Dosage usually lower Benzodiazepines Short-term for agitation

Other Medication Issues Monitoring important Side effect monitoring important because taking more than one medication Drug-drug interactions Especially, alcohol, drugs, OTC and herbal supplements Teaching points Lithium (Change in salt intake can affect lithium.) Most of these medications cause weight gain. Check before using OTC.

Nursing Management: Psychological Domain Assessment Mood Cognitive Thought Disturbances Stress and coping factors Risk assessment Nursing Diagnosis Disturbed sensory perception Disturbed thought processes Defensive coping Risk for suicide Risk for violence Ineffective coping

Nursing Management: Social Domain Assessment Social and occupational changes Cultural views of mental illness Nursing Diagnosis Ineffective role performance Interrupted family processes Impaired social interaction Impaired parenting Compromised family coping

Nursing Interventions: Social Domain Protect from over-extending boundaries Support groups Family interventions Marital and family interventions

Continuum of Care Inpatient management – short-term Intensive outpatient programs Frequent office visits Crisis telephone calls Family session or -